Somatic and Related Disorders

Admin notes and announcements

• Fire drill on campus tomorrow at 11:00 AM. If you’re not here at 11:00, you won’t be able to get back in. Everyone present will exit the building.
• Drill duration: about 10–15 minutes; typically you’re guided to walk to the parking lot.
• Administrative reminders about applications and campus systems:
  • Those starting health-related programs should check for the SABA email from BJC; it has to be completed within 48 hours (the desk may say 24, but that window is not reliable).
  • When the system cycles, it may not always work; the 48-hour window is recommended.
  • Do not fast forward through steps (they can monitor progress).
• Clinical schedules and holiday impacts:
  • Look at your clinical schedule carefully. For example, a pediatric group finishing Thursday may not have their first site clinical until Monday the 29th.
  • Some of you may have psych clinical on Monday the 22nd and PEETS clinical on the 25th; Labor Day and other Monday holidays can shift Monday clinics.
  • Fall semester often has more Monday holidays that complicate scheduling, with January/February holidays mentioned as well.
• Recording and attendance logistics:
  • Many students record sessions; side conversations may show up in recordings. Please minimize side conversations to avoid noise in the recording.
  • Some students are sick and rely on recordings; it’s important they can hear the material.
  • If you are recording, you may place your device up here next to the instructor; there have been semesters with phones covering the whole room.
• Today’s topic preview:
  • We’re starting with somatic and related disorders. Reference: ATI book, page 129.
  • This topic can be challenging to understand because it links psychological distress to physical symptoms.
• Quick scheduling note:
  • Five-minute bathroom break option if needed; otherwise, we’ll continue.

Somatic and related disorders: overview (ATI, page 129)

• Core idea: somatic disorders express psychological stress through physical manifestations; e.g., a mental health crisis presenting as GI upset or a headache.
• Common example: when stressed, people may have diarrhea or headaches; the focus here is on more extreme presentations where physical symptoms cannot be explained by underlying pathology.
• Key clinical point:
  • These physical manifestations must be ruled out for underlying medical disease before attributing them to a somatic disorder.
  • Patients with somatic concerns often have high healthcare utilization due to persistent symptoms.
  • The symptoms are real to the patient, even if an independent medical validation isn’t possible.
• Assessment tool: PHQ-15 (primary healthcare setting for chronic physical symptoms).
  • It’s a standardized tool used to screen for somatic symptom burden.
  • Symptom domains include a range of bodily complaints (see item list below).
  • Response levels (three-level scale):
  • 0 = ext{Not bothered at all}
  • 1 = ext{Bothered a little}
  • 2 = ext{Bothered a lot}
• Common physical manifestations reported in somatic disorders (examples):
  • Stomach pain, back pain, joint pain, menstrual cramps, headache, chest pain, dizziness,
  • Fainting spells, feeling the heart pound or race, shortness of breath, pain or problems during intercourse,
  • Bowel issues, other GI issues, tiredness, low energy, trouble sleeping.
• PHQ-15 items (as listed in the transcript; 15–16 items are referenced in the session):
  • stomach pain
  • back pain
  • joint pain
  • menstrual cramps
  • headache
  • chest pain
  • dizziness
  • fainting spells
  • feeling your heart pound or race
  • shortness of breath
  • pain or problems during intercourse
  • bowel issues
  • other GI issues
  • tired
  • low energy
  • trouble sleeping
• Important nursing principle:
  • Acknowledge that the symptoms are real to the client even if there is no identifiable medical pathology.
  • Use therapeutic communication to establish rapport and validate the patient’s experience.
  • Include suicide or self-harm risk assessment as part of the evaluation.
• Secondary gains in somatic presentations:
  • Secondary gain = what the patient gains from presenting with symptoms (conscious or unconscious mechanisms).
  • Examples:
  • Attention: “look at me” due to overwhelming stress at home or other responsibilities.
  • Distraction from personal problems or responsibilities by focusing on health concerns.
  • In cases like a newborn at home, chronic stress can contribute to somatic symptoms that shift attention away from overwhelm.
• Treatment goals and approaches:
  • Promote independence and coping strategies; encourage engagement in daily activities and exercise.
  • Therapeutic modalities: group therapy, individual therapy, antidepressants, anxiolytics, OTC analgesics as appropriate.
  • A treatment approach described: retro reactivation treatment (note: terminology in the transcript; often framed as reactivation or stepped care in practice).
• Clinical communication strategy (Stage-based approach):
  • Stage two: broaden the agenda, acknowledge concerns, and review diagnostic studies.
  • Provide a clear link between negative medical findings and the psychological aspects of the symptoms.
  • Maintain patient self-esteem by validating feelings while noting that GI studies, stool cultures, X-rays, and Helicobacter pylori testing have all been unrevealing.
  • Stage three: continue to support coping and self-management through therapy and pharmacologic treatment as needed.
  • Stage four: negotiate a tapering plan for urgent visits, e.g., schedule visits every 6 weeks, then every 4–5–6 weeks, to gradually reduce urgent appointments while continuing therapy and medications.
• Terminology evolution (DSM-5 era):
  • Hypochondria is now referred to as Illness Anxiety Disorder.
  • Illness Anxiety Disorder can involve obsessive thoughts/fears of illness and patterns of care-seeking or care avoidance.
  • The clinician can rule out physical illness with appropriate diagnostic tests when a patient presents with health anxiety.
• Conversion disorder (Functional Neurological Symptom Disorder):
  • Neurological symptoms occur without an identifiable neurological disease.
  • Possible manifestations include: seizure-like movements, blindness, inability to speak or smell, numbness, deafness, tingling, burning sensations, and even a false pregnancy.
  • The manifestation is real to the patient and requires ruling out neurological causes, which can be costly and time-consuming.
• Factitious disorder and Munchausen spectrum:
  • Factitious disorder: conscious fabrication or induction of physical/psychological symptoms to assume the sick role.
  • Munchausen syndrome: older term for factitious disorder where the patient fabricates disease without an obvious external incentive.
  • Factitious disorder imposed on another (Munchausen by proxy): the caregiver induces illness or injury in someone else (often a vulnerable person such as a child), to gain attention or manipulate caregiving dynamics.
  • Real-world clinical note from the transcript: a pediatric case involving a 12-year-old with recurrent DKA (blood glucose up to ~800 mg/dL) and an insulin infusion; the caregiver (mother) would drop off the younger sibling, and the patient would manipulate insulin administration to remain hospitalized and gain attention and validation. This example illustrates how attention-seeking and caregiver dynamics can drive factitious presentations.
• Case example recap (pediatric care context):
  • A 12-year-old with Type 1 diabetes presented with severe hyperglycemia requiring ICU management (DKA) and insulin drips.
  • The caregiver’s pattern included attempting to bring the younger sibling to the hospital and allowing or facilitating the hospitalized child’s need for attention.
  • Investigations showed normal or non-contributory findings from standard checks (CGM-era context not specified; emphasis on the caregiving pattern and attention-seeking behavior).
  • The clinical takeaway: be alert to possible Munchausen by proxy when caregiver behavior centers around hospitalizations and the patient exhibits anomalous patterns of illness without a clear medical basis.
• Practical implications and clinical stance:
  • These disorders require time and compassionate engagement; they are real to the patient, and empathetic, patient-centered care is essential.
  • Clinicians should balance ruling out serious medical conditions with addressing psychological and social factors contributing to the presentation.
  • Ethical considerations include safeguarding patients when there is concern about caregiver-driven harm (e.g., Munchausen by proxy).
• Quick synthesis points for exams:
  • Distinguish somatic symptom disorder from illness anxiety disorder by noting persistent somatic symptoms with distress and impairment (somatic symptom disorder) versus preoccupation with having or acquiring a serious illness without significant somatic symptoms (illness anxiety disorder).
  • Conversion disorder involves genuine neurological symptoms without an identifiable organic cause; consider severe functional impairment but with a neurological explanation inconsistent with known disease.
  • Factitious disorder involves intentional production or feigning of symptoms for psychological gain (attention, care) without obvious external incentives; Munchausen by proxy involves harming or manipulating another person (often a child) to secure care or attention.
• Memory cues and exam-ready points:
  • Remember the PHQ-15 as a standardized somatic symptom screening tool used in primary care to assess chronic physical symptoms.
  • Recognize the pattern of high healthcare utilization in somatic symptom disorders due to ongoing symptom reporting and the need to rule out pathology.
  • Be prepared to discuss staging of care and patient progression from urgent visits toward regular therapy and monitored follow-up to reduce crisis-driven care.
• Connections to clinical practice and ethics:
  • Validate patient experience while guiding them toward appropriate mental health interventions.
  • Use collaborative communication to avoid confrontation about “being non-physical” and instead frame symptoms as distress signals requiring a biopsychosocial approach.
  • Be vigilant for signs of caregiver-driven illness in pediatric cases and know when to involve safeguarding or interdisciplinary teams.
• Key terms to review:
  • Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder (Functional Neurological Symptom Disorder), Factitious Disorder, Munchausen by Proxy, Secondary Gains, PHQ-15, Therapeutic Communication, Stage-based Management, Illness Anxiety Symptoms, Neurodiagnostic Ruling-Out Process, Reassessment and Weaning from Urgent Care.
• Final take-home message:
  • Somatic and related disorders lie at the intersection of psychology and medicine; patients are real and deserve careful assessment, empathetic communication, and a structured plan that includes medical ruling-out, psychosocial support, and a gradual shift toward healthier coping mechanisms and reduced reliance on emergency or urgent care.